National policy on early detection of developmental-behavioral/social-emotional/mental health problems

Our goals, no matter what our professional backgrounds or the types of practices in which we work, are to prevent, detect, and intervene with developmental-behavioral problems as early as possible. In doing this we facilitate children’s success in school and thus life. If we can help children do well, they are far more likely to graduate, hold jobs, and avoid teen pregnancy and criminal behavior. And, early detection and intervention confer not only enormous social benefits but also save tax payers enormous amounts of money: For every $1 we spend on early intervention, we save between $13.00 and $17.00.

The USA is fortunate to have passed the Individuals with Disabilities Education Act (IDEA) and the Americans with Disabilities Act (ADA). IDEA guarantees a free and appropriate education for children with disabilities starting at birth until age 22 (IDEA provides Early Intervention (for children 0 – 3) and public school special education (SE) (for children 3 to 22.)

ADA and Section 504 of the Rehabilitation Act guarantees right to access (and is thus responsible for services like wheel-chair ramps and behavior management programs in regular education classrooms that help children with attention-deficit disorder, get the extra help they need to succeed at grade level).

- - -

Although the effectiveness of early intervention is well established, almost all States find Early Intervention (EI) enrollment rates are well below prevalence figures established by the Centers for Disease Control (see https://www.ideadata.org) for details. This means that early detection and referral to EI are problematic. Since health care settings is “where the kids are”, many States focus on requiring health care providers to improve the methods by which they identify children with difficulties.

Several States (e.g., Tennessee, North Carolina, Hawaii, Massachusetts, Texas, Connecticut) have established their own mandates dictating the use of quality screens. If you look at CDC data, you’ll see that States requiring quality screens, have far higher EI enrollment rates than do States without mandates. Note, however, that criteria for enrollment vary from State to State (e.g., Connecticut has stringent criteria but enrollment rates are far higher there than in other States similar criteria but without mandates for use of quality measures. Hawaii, with far less stringent criteria, comes closest to having EI enrollment that equals prevalence rates—clearly because it has long-demanded use of quality tools). If you look at enrollment rates over the past few years, you’ll see increases within States requiring accurate tools.

- - -

Because most families with young children are seen by health care providers, the American Academy of Pediatrics (AAP) policy on early detection policy is typically adopted by nursing societies, family practice providers, and public health services (and is enthusiastically supported by special educators, psychologists, speech-language pathologists, child welfare workers, etc.).

The AAP’s current policy on early detection covers two procedures and concepts (along with prompt referring when problems are suspected):

3. Observing the child (and family), maintaining a family and child medical history, and identifying (and continuing to look for) risk and protective (also known as resilience) factors.

Screening, i.e.,:

4. Administering an autism-specific screen at 18 and again at 24 months

5. Administering periodically an accurate screen focused on all areas of development and behavior, starting at 9, 18, 24 – 30 months, and then continuing “a pattern and practice of attention to development that can and should continue well beyond 3 years of age.”

Most folks have questions about the AAP policy! Some of the most common are these:

Q: Do we need separate tools for surveillance and screening?

A: No! Screening and surveillance do not have to be separate processes relying on different sets of tools. Rather, both tasks can be accomplished at the same time [e.g., using PEDS (for the surveillance task of eliciting and addressing parents’ concerns but also using its evidence-based scoring as a screen, i.e., to determine risk levels/referral needs ); and PEDS:DM for monitoring milestones but also relying on its cutoffs and thus to also use it as a screen to determine when referrals are needed. The PEDS:DM also contains an autism-specific screen, a psychosocial risk screen, a resilience measure, measures of mental health, tools for screening older children, etc.

So bottom line, you can conduct surveillance and screen at the same time, AND the decisions you make will be far more accurate if you use accurate tools. (More information on making this policy doable is elsewhere on our site).

Q: So we can stop screening after 24- 30 months?

A: No way! Screening and surveillance cannot stop at 24- 30 months. That is not at all what the AAP intended: We know that we can’t see all disabilities and delays at very young ages [e.g., expressive language disorders, learning disabilities in reading, writing or math all develop (and are more and more measurable) with time]. This means we must keep screening throughout childhood and adolescence. The AAP is fighting hard with private payers who want to stop reimbursing for screening at 24 – 30 months. So remember that AAP policy recommends that their recommendations for screening and surveillance at young ages should establish “a pattern and practice of attention to development that can and should continue well beyond 3 years of age.”

Q: Do the checklists on our age-specific encounter forms, selected items from the Denver-II count as screening/surveillance and thus receive reimbursement?

A: No! Most payers (Medicaid and private) require providers to use accurate, validated tools. Quality measures should always be used, not only to improve reimbursement but also to best assist children and families.